|Year : 2015 | Volume
| Issue : 7 | Page : 12-26
|Date of Web Publication||24-Nov-2015|
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
. Breast. J Can Res Ther 2015;11, Suppl S3:12-26
Carcinoma breast presenting with metastasis to uterine cervix: A case report
thA. Arjunan , S. Ibrahim, S. Mathews, P. G. Jayaprakash
Regional Cancer Centre, Trivandrum, Kerala, India, E-mail: [email protected]
Introduction: Metastasis of breast cancer to uterine cervix is extremely rare and even rarer is the diagnosis of cervical metastasis before the breast primary is diagnosed. We report a case of breast cancer in a 47 year old woman who presented with metastasis to uterine cervix. Case Report: 47 year old perimenopausal woman with no significant past medical or surgical history was referred to our centre with a diagnosis of right supraclavicular nodal metastasis from unknown primary. Clinical examination revealed an indurated swelling involving right supraclavicular fossa with a well healed surgical scar. There was mild retraction of right nipple with a vague induration in the lower inner quadrant of right breast. Pervaginal examination revealed a bulky hard indurated cervical growth on posterior lip which was biopsied and reported as metastatic adenocarcinoma. Chest X-ray was normal. Ultrasound scan showed bulky cervix. Bone scan revealed multiple areas of increased uptake suggestive of metastasis. Incisional biopsy from the indurated region of right breast was reported as invasive lobular carcinoma, positive for oestrogen and progesterone receptors. She was initially started on anthracycline based chemotherapy, which was discontinued after 6 cycles due to disease progression. She subsequently progressed on endocrine therapy and second line chemotherapy with Docetaxel. She also developed extensive erythematous skin lesions over right hypochondrium and right anterior chest wall with discharging sinuses, for which a diagnosis of Carcinoma Erysipeloides was made. She eventually died of progressive disease. Discussion: Although metastatic tumour to the uterine cervix from breast cancer is rare, there are previous reports of the same in literature. Its importance lies in the fact that it may be mistaken for primary cervical cancer.
Feasibility of deep inspiratory breath holding technique versus normal breathing in patients of carcinoma breast undergoing radiation therapy: A dosimetric study
Karnataka Cancer Therapy and Research Institute, Hubli, Karnataka, India, E-mail: [email protected]
Aims: (1) Comparing the ipsilateral lung volumes in normal breathing and in deep inspiratory breath holding technique. (2) To evaluate the dose received by the heart, opposite breast, ipsilateral lung as well as PTV in both sets of patients. Materials and Methods: 50 patients of proven breast cancer from January 2015 to August 2015 were selected for our study. All these patients underwent immobilisation using an aquaplast cast and planning CT scan of thorax was done. The CT scan was initially done in normal breathing and later in breath holding technique with patient being told to withhold his breath after deep inspiration. The two sets of images were transferred to our treatment planning system and contoured separately. The organs at risks were ipsilteral lung, heart, opposite breast. Contouring of CTV and PTV were also done and best possible distribution was obtained for these patients. Results: In our study of 50 breast cancer patients undergoing radiation therapy we observed that the lung volumes increased significantly in case of DIBH technique (1490 cc) as compared to normal breathing (1016 cc) with a p value of 0.006. Similarly the dose received by ipsilateral lung was also reduced from 19.2 Gy to 5.03 Gy with a p value of 0.0058, while the opposite breast dose reduced from 1.37 Gy to 0.48 Gy with a p value being statistically significant (p - 0.0003). The dose received by heart reduced from 1.85 Gy to 1.20 Gy. The PTV coverage in both the set of patients ranged from 95% to 104% with a dose of 49.4 Gy in normal breathing and 50.6 Gy in DIBH technique. Conclusion: There is significant reduction in doses to ipsilateral lung as well as opposite breast using DIBH technique compared to normal breathing. However this being a dosimetric study clinical evaluation is necessary to put it in clinical practice.
Spirometric changes in carcinoma breast patients following radiation therapy
thN. Sindhu , I. Ahmed, A. Kadam, J. Rajesh, V. Chendil
Bangalore Medical College and Research Institute, Bengaluru, Karnataka, India, E-mail: [email protected]
Background: Lung is the main organ at risk for radiation induced injury while treating breast cancers with radiotherapy (RT). Restrictive lung changes are usually seen in spirometry which tends to normalize by 1 year. Central lung distance (CLD) is shown to correlate well with the percentage of ipsilateral lung volume irradiated. Aim: Spirometric changes following radiotherapy to chest wall in carcinoma of breast patients and its correlation with acute radiation pneumonitis. Materials and Methods: Breast cancer patients who received radiotherapy to chest wall +/- supraclavicular fossa and axilla, following modified radical mastectomy and chemotherapy (4 cycles of taxanes and 4 cycles of adriamycin and cyclophosphamide), using tangential beams with Co60 teletherapy to a dose of 50 Gray in conventional fractionation were included and followed up till 6 months post RT. All patients underwent computerized tomography (CT) simulation and CLD was documented. Baseline chest X-ray and spirometry done pre-RT was compared with those taken at 1, 3 and 6 months after completion of RT. Clinical examination was done during each visit and radiation pneumonitis if present was graded as per RTOG criteria. Results: 20 female breast cancer patients (stage IIA to IIIC) aged 32-75 years (mean - 54.5 years) were studied. The simulation CT of these patients showed a mean CLD of 2.05 cm which was under acceptable limit given by European Organization for Research and Treatment of Cancer (EORTC) and European Society of Mastology (EUSOMA). There was a significant fall in forced vital capacity (FVC) by the end of 3 months (p value < 0.01) which improved by 6 months without any active intervention in 95% of the patients. Mean baseline FVC was 83% which decreased to 70% by the end of 3 months and 79% at 6 months. Forced expiratory volume in first second (FEV1) and FEV1/FVC did not show any significant change compared to baseline. Spirometric changes correlated with reversible restrictive lung changes. One out of 20 patients developed symptomatic acute radiation pneumonitis (5%) of grade 3 severity who had moderate restrictive changes. Conclusion: Significant decrease in forced vital capacity of the lungs is present following radiation therapy in carcinoma of breast patients in the initial 3 months which tends to normalize by 6 months. 5% of the patients develop symptomatic acute lung toxicity which can be further reduced by minimizing irradiated lung volume.
Dosimetric comparison of imrt with 3DCRT in whole breast irradiation: A single institutional experience
thS. Rajan , B. K. M. Reddy, V. Natrajan, M. S. Belliappa, V. Bhaskar, N. Ramar
Apollo Hospitals, Bengaluru, Karnataka, India, E-mail: [email protected]
Background: Whole breast irradiation followed by boost is part of breast conservative management for early breast cancer. In this study we attempt to compare and analyse the dosimetric aspects of IMRT over 3DCRT in breast irradiation. Aim: To compare conformity and homogeneity indices of target doses, and organ at risk doses (lungs and heart), between IMRT and 3DCRT in whole breast irradiation. Materials and Methods: We took the treatment planning data of 220 consecutive patients, treated with 6 MV photons, in Varian 600C and Varian Truebeam STx, for our retrospective study. Dose prescribed was 50-50.4 Gy/25-28 fractions to whole breast (1.8-2 Gy/Fraction) and 10-16 Gy/5-8 fractions boost to Lumpectomy cavity (2 Gy/Fraction). The prescribed dose is delivered in a 5 fraction per week schedule. Conformity Index and Homogeneity index of target dose; and doses to Organs at Risk were compared and analysed. Results: Breast PTV volumes ranged from 867.1 to 2503.3 cc. Conformity index for IMRT technique is higher than that of 3DCRT (0.845 and 0.78 respectively). Homogeneity indices were not found to be significantly different between IMRT and 3DCRT (0.104 and 0.101 respectively). All parameters such as V20, V30, mean lung doses are lower for IMRT than 3DCRT. V5 lung is significantly higher for IMRT than that of 3DCRT (55.86 and 26.99). Similarly, V30 and Mean heart doses are lesser for IMRT than 3DCRT. Conclusion: The IMRT technique reduces the doses to lung and heart than 3DCRT technique without compromising the target coverage. In this study, the ipsilateral lung low dose parameters were observed to have higher values in IMRT technique than 3DCRT technique. The clinical significance of this higher low dose volume is to be evaluated.
Randomised prospective trial comparing hypofractionated radiation therapy and conventional radiation therapy in post mastectomy carcinoma of breast
thG. H. Abhilash , V. Kaushal, A. K. Dhull, R. Atri, R. Dhankhar
Post Graduate Institute of Medical Sciences, Rohtak, Haryana, India, E-mail: [email protected]
Background: Post mastectomy radiation plays an essential role in management of breast cancer by eradicating subclinical disease and reducing locoregional recurrence. Hypofractionation demonstrated equivalent local control and normal tissue toxicity outcomes with conventional fractionation. Aim: To compare local control and side effects of hypofractionated radiation therapy with conventional radiation therapy in post mastectomy carcinoma breast with stage II and III. Materials and Methods: The present randomized prospective study was conducted on forty previously mastectomised, histopathologically proven patients of breast carcinoma required treatment by radiation therapy. The patients were divided into 2 groups. Study Group these patients were given external radiation to chest flap and drainage areas, delivering a dose of 39 Gy/13 fractions/3.1 weeks, to receive a daily dose 3 Gy for 13 fractions in a 4 days a week schedule. Control Group these patients were given external radiation to chest flap and drainage areas, delivering a dose of 50 Gy/25 fractions/5 weeks, to receive a daily dose 2 Gy for 25 fractions in a 5 days a week schedule. Results: In study group, local control was achieved in 19 (95%) patients and 1 (5%) patient developed local recurrence and also distant metastases. Grade I, II, III and IV skin reactions were seen in 12 (60%), 6 (30%), 1 (5%) and 1 (5%) patients respectively. Grade I dysphagia reported by 4 (20%) patients and no case of radiation pneumonitis was observed. In control group, local control was achieved in all the 20 (100%) patients and no patient developed local recurrence or distant metastases. Grade I, II, III and IV skin reactions were seen in 14 (70%), 5 (25%), 1 (5%) and 0 patients respectively. Grade I dysphagia reported by 2 (10%) patients and no case of radiation pneumonitis were observed . Conclusion: The study group showed comparable local control and acute toxicity profile with control group, but with lesser treatment time, better compliance was reported with study arm. However, larger study with longer follow-up is required for assessment of late toxicity and overall survival.
A prospective study on toxicity and quality of life of postmastectomy external beam radiation followed by HDR surface mould brachytherapy boost in high risk cases
thA. Halder , R. Tudu, B. Dutta, N. Biswas, D. Barman, A. R. Deb
Kolkata Medical College, Kolkata, West Bengal, India, E-mail: [email protected]
Background: In India majority of ca. breast cases are diagnosed in locally advanced stage (LABC). Surgery (Mastectomy) & Chemotherapy is mainstay of treatment, though Radiotherapy is also required. Skin toxicity is major concern for chest wall irradiation following mastectomy. The lung is the major dose-limiting organs for radiotherapy here. Post-Mastectomy Radiotherapy (PMRT) with conventional fractionation is the standard of care in LABCs undergoing Modified Radical mastectomy (MRM). Scar boost using electrons is done in high risk cases. But in certain centres Linac & electron-therapy is unavailable but HDR Brachytherapy is available. So surface mould Brachytherapy scar boost could be a viable alternative in this scenario. Aim: To evaluate the feasibility of scar boost using HDR-Brachytherapy- surface mould after Conventional PMRT, in high risk cases. And to evaluate whether the skin & pulmonary toxicities during & after treatment is tolerable & whether Quality of life (QOL) is acceptable. Materials and Methods: A single institutional prospective study during October 2013 to March 2015 with 12 patients of LABC who were treated with MRM followed by chemotherapy followed by EBRT with a sequential brachytherapy boost to scar. The inclusion criteria for study were: Any high-risk features: Close margin (<= 2 mm) or Positive margins with (1) Unilateral Female ca. breast patient. (2) Age 20-60 years. (3) Biopsy proven invasive ductal carcinoma (IDC) treated with MRM & chemotherapy. (4) T size >5 cm. (5) N2-N3 disease. (6) ECOG<=2. (7) Baseline normal haematological, renal and hepatic profile & cardiac & pulmonary function. Radiation was given in two phases: (I) EBRT to chest wall & SCLN+axilla (if indicated) with 50 Gy/25# by Co-60 Tele-therapy. (II) HDR-Brachytherapy (Ir-192) scar boost using Surface mould, of 10 Gy/4#. Brachytherapy was given after 2 weeks of EBRT completion. Outcome was assessed in terms skin & pulmonary toxicities and QOL. Results: 5 patients had grade III skin toxicity at 3 weeks of follow up & 3 patients had grade II skin toxicity at 6 weeks. 2 patients developed grade II pulmonary toxicity at 12 months & none at 18 months. 1 patient was lost to follow up. 1 patient died of brain metastases after 6 months. The QOL was satisfactory at end of follow up period. Conclusion: Surface-mould brachytherapy after EBRT is a feasible treatment of high risk post-mastectomy cases with low probability of severe complications & acceptable QOL.
Comparison of two different fractionation schedule in treatment of early breast carcinoma
thS. S. Chandel
Gajara Raja Medical College, Gwalior, Madhya Pradesh, India, E-mail: [email protected]
Background: The standard radiotherapy schedule for early breast cancer delivers 50 Gy in 25 fractions of 2.0 Gy over 5 weeks, but non-standard regimens delivering a lower total dose using fewer, larger fractions (hypofractionation). We aimed to test the benefits of radiotherapy schedules using fraction sizes larger than 2.0 Gy in terms of locoregional tumour control, normal tissue responses, quality of life in women prescribed post-operative radiotherapy. Materials and Methods: Between January 2012 to December 2014, in department of radiotherapy and oncology, retrospective and prospective evaluation of 82 women's with early stage breast cancer (stages I &II) treated with 50 Gy in 25 fractions of 2.0 Gy over 5 weeks or 40 Gy in 15 fractions of 2.67 Gy over 3 weeks after primary surgery. Eligibility criteria were age between 25 to 65 years, no prior chest irradiation and were available for follow-up. All patients also received 6 cycle of chemotherapy CAF or CEF regimens. Results: 42 women were treated with 50 Gy group and 40 women to the 40 Gy group. After a median follow up of 22 months the rate of locoregional tumour relapse was almost similar in both group. Acute radiation reaction was slightly higher in 40 Gy group. Photographic and patient self-assessments indicated lower rates of late adverse effects after 40 Gy than after 50 Gy. Conclusion: A radiation schedule delivering 40 Gy in 15 fractions seems to offer rates of local-regional tumour relapse and late adverse effects at least as favorable as the standard schedule of 50 Gy in 25 fractions. As results of our study we suggest that 40 Gy in 15 fractions are safer and better for high patients loaded government setup.
Is IMRT superior to 3D-CRT for post-mastectomy loco-regional irradiation? An in silico comparative planning study
Batra Hospital and Research Centre, New Delhi, India
E-mail: [email protected]
Background: Is IMRT superior to 3D-CRT for post-mastectomy loco-regional irradiation? An in silico comparative planning study. Aim: To perform an in silico comparative planning to evaluate IMRT versus 3D-CRT during irradiation of ipsilateral chest wall (CW), axilla/supraclavicular (AXSCF) and internal mammary (IM) regions in post-mastectomy breast cancers (PMBC). Materials and Methods: Twenty-five consecutive patients of PMBC, stages T2-3 with N1-3 were considered for this study. A total dose of 50 Gy/5 weeks/25 fractions were planned on identical target volumes and normal tissue contours by either IMRT or five-field 3D-CRT. Treatment plans were evaluated for various dose-volume histogram parameters, namely D98, D90, D50, D2, homogeneity index (HI) to the CTV and PTV of the respective CW, AXSCF and IM along with V20 to lung and D33 to the heart. Differences in means were tested for significance by paired sample t-test. Results: The DVH parameters for various target volumes and OARs show that IMRT plans have a significant dosimetric advantage over the 3D CRT plans in almost all key parameters. Even with the inclusion of IMC, the lung and cardiac doses are lower with IMRT. However, the mean dose to the opposite breast is higher with IMRT. None of the 25 patients treated with IMRT have not shown any loco-regional recurrence, pulmonary or cardiac toxicities at a median follow up of 2.9 years (range: 2.8-3.9 year). Conclusion: In indications of irradiation to chest wall and all regional nodal sites in PMBC, IMRT provides significant dosimetric advantages over five field 3D-CRT. This was also evident clinically, on follow-up of these patients treated with IMRT.
Incidental radiation dose to axilla and internal mammary nodal area in patients undergoing chest wall radiation in carcinoma breast; treatment of micrometastasis versus unnecessary toxicity
thN. Begum , H. B. Govardhan, I. Kaleel, P. Sridhar, T. Naveen,
P. Siddanna, K. P. R. Pramod, D. S. Nehanty
Kidwai Memorial Institute of Oncology, Bengaluru, Karnataka, India, E-mail: [email protected]
Aim: This study attempts to quantify the incidental dose delivered to axilla and internal mammary area by three techniques (conventional tangential, 3DCRT, and IMRT), which might help us understand the role of incidental radiation in controlling microscopic disease and/or increasing the incidence of toxicity. Materials and Methods: We prospectively evaluated incidental radiation to axilla and internal mammary area in twenty five cases of breast cancer (T 1-4, N-0-1, M-0) treated with adjuvant radiation therapy. Three plans were generated for each case, comprising CT, 3DCRT and IMRT tangents. Radiation doses to axillary levels I, II, III, and IMN areas were evaluated for mean dose, V95, V90, V80 and V50. Comparisons were made using ANOVA. Results: The mean volume and range of the axillary level I, II, III, and IMN were 61.1 cc and 142-57 cc; 42.6 cc and 61-21 cc; 19.5 cc and 34-15 cc; 13.2 cc and 21-9 cc respectively. The mean dose by 3 techniques (by IMRT, 3DCRT, and CT) to Level I were 75%, 81%, and 92% to level II were 53%, 64% and 86%, to level III were 38%, 44% and 53%, to IMN were 61%, 77% and 92% respectively (p < 0.05). The V95 values (volume receiving 95% of dose) for the three techniques were 43%, 39%, 17% and 49% by IMRT: 40%, 45%, 21%, and 59% by 3DCRT; 72%, 61%, 24%, and 65% by CT (IMRT vs 3DCRT for level II axilla, IMRT vs CT and 3DCRT vs CT-p < 0.05) The V80 were 49%, 53%, 29%, and 57% by IMRT;55%, 47%, 34% and 68% by 3DCRT; 85%, 77%, 44%, and 69% by CT (IMRT vs 3DCRT for level III axilla and IMN, IMRT vs CT and 3DCRT vs CT-p < 0.05). The V50 values were 75%, 65%, 41%, and 66% by IMRT; 82%, 53%, 57%, and 84% by 3DCRT; 94%, 89%, 42%, and 90% by CT (IMRT vs 3DCRT, IMRT vs CT, and 3DCRT vs CT p < 0.05). Conclusion: During radiation to the chest wall, a substantial incidental radiation dose is also delivered to the axilla and internal mammary nodal area which deals with micro metastasis/isolated tumor cells but, however, leads to additive toxicity. Among the three techniques, incidental mean radiation dose to axilla and internal mammary nodes is low in IMRT followed by 3DCRT and conventional tangential beam, therefore before starting the treatment, the clinical benefits of the incidental radiation versus the limitation of the toxicity have to be taken into consideration. Based on this study we propose that in cases where conformal radiation technique is used in low risk axillary nodes, constraints to the axillary nodes should be followed as in critical organ group.
Do different contouring guidelines result in difference in the reported doses to the target volumes for whole breast radiotherapy?
thR. Patil , V. Mhatre, A. Nachankar, P. Patwe, P. Dandekar
Sir. H. N. Reliance Foundation Hospital, Mumbai, Maharashtra, India, E-mail: [email protected]
Aim: To investigate whether conventional RT breast portals deliver adequate doses to target volumes contoured as per RTOG and ESTRO guidelines. Materials and Methods: Four patients treated with left sided breast cancer who had undergone breast conservation surgery were planned for whole breast radiotherapy using clinically determined landmarks. The breast was planned using field in field bi-tangential portals. The supraclavicular field covered the supraclavicular fossa laterally up to the humeral head with humeral head shielding and dose to the supraclavicular field was prescribed at a depth of 3 cm with the beam angled at 10 degrees. Dose prescribed was 50 Gy in 25 fractions. The RTOG and ESTRO target volumes (TVs) were contoured. Dose-volume histograms (DVH) were computed for the RTOG TVs and ESTRO TVs DVH parameters were compared. Statistical analysis was conducted using Microsoft excel 2013. Results: The nodal volumes for RTOG and ESTRO TVs differed with significant difference observed for Axillary level II (RTOG mean (+/- 95% CI) = 10.45 cc (+/- 5.5), ESTRO mean = 8.74 cc (+/- 5.6), p = 0.05) and Supraclavicular/level IV TVs (RTOG mean = 23.97 cc (+/- 3.56) = 13.02 cc (+/- 4.64), ESTRO mean = 8.74 cc (+/- 5.6), p = 0.0002). The RTOG and ESTRO breast TVs were similar (average = 1119 cc, range: 929 - 1393 cc). The RTOG and ESTRO breast TVs were similar (average = 1119 cc, range: 929 - 1393 cc). The RTOG and ESTRO breast TVs were similar (average = 1119 cc, range: 929 - 1393 cc). For RTOG and ESTRO Breast TVs the average D 95% (+/- 95% CI) was 42 Gy (+/- 15.5). For RTOG and ESTRO Axillary level I TVs average D95% (+ 95% CI) was 22.5 Gy (+/- 15.5) and 18.7 Gy (+/- 11.4) respectively. For RTOG and ESTRO Axillary level II TVs average D95% (+/- 95% CI) was 33 Gy (+/- 18) and 27 Gy (+/- 5.8) respectively. For RTOG and ESTRO Axillary level III TVs average D95% (+/- 95% CI) was 38 Gy (+/- 14.8) and 31 Gy (+/- 15.5) respectively. For RTOG and ESTRO Supraclavicular/level IV TVs average D95% (+/- 95% CI) was 35 Gy (+/- 31) and 25 Gy (+/- 36) respectively. Conclusion: The conventional RT portals are inadequate for dosimetric coverage of the TV contours defined by RTOG and EORTC. Heterogeneity exists between the RTOG and EORTC TV guideline. The difference between the two guidelines may affect the dosimetric outcomes reported by studies.
Clinico-pathologic analysis and outcome of male breast cancer: Experience from a tertiary cancer center
thR. Upadhyay , P. Kumar, G. K. Rath, P. K. Julka, D. N. Sharma,
A. Srivastava, K. P. Haresh, S. Gupta
All India Institute of Medical Sciences, New Delhi, India, E-mail: [email protected]
Background: Cancer of the male breast (MBC) accounts for about 1% of all malignancies in men and 1% of all breast cancers. Lack of awareness often leads to late presentation and delayed diagnosis in our setting. Aim: To analyze the demography, clinical features, pathology, management and outcome of MBC in patients treated in our department. Materials and Methods: Retrospective review of MBC patients from 2005 to 2015 - 35 cases were identified from our departmental archives. AJCC 2010 was used for staging. Kaplan Meier method was used for estimation of progression free survival (PFS). Results: Mean age was 54 years (range 28-82 years). 77% of patients presented with breast lump. 29% had breast pain while nipple retraction, nipple discharge and axillary swelling were noted in 11%, 14% and 11% patients respectively. All cases were unilateral (21 on right, 14 on left). The number of patients with clinical stages I, II, III and IV were 4%, 36%, 36% and 24% respectively. Histopathology revealed infiltrative ductal carcinoma in 88% and lobular carcinoma, medullary carcinoma, fibrosarcoma and benign phyllodes tumor in 3% each. Of 24 patients in whom hormone receptor (HR) study was performed, 79% were HR positive and 71% were estrogen receptor positive. Her-2/neu status was done in 23 patients; only 26% were positive. Of the 32 treated patients, 26 patients underwent surgery (including 3 after neoadjuvant chemotherapy) and 6 received palliative chemotherapy. Modified radical mastectomy was done in 81%, radical mastectomy in 8% and wide local excision in 11%. Of these, 74% were found to be pathologically node positive. Adjuvant chemotherapy and radiotherapy were given to 17 and 14 patients respectively. All HR positive patients received tamoxifen. Median follow up was 13.5 months (range 2 -132 months). 1 patient developed local recurrence (at 120 months) and 6 patients developed distant metastasis (23%) over 2 to 120 months. These included 2 patients each with bone, lung and liver metastasis and one with brain metastasis. The 2 year estimated PFS rate for the entire cohort was 75.8%. Conclusion: MBC mostly present in advance stages in our centre. Majority of them harbor HR positive disease with low HER-2 overexpression. These patients are managed similar to female breast cancers. Further follow up of these cohort of patients are needed for accurate evaluation of failure patterns and survival outcomes.
Role of hypofractionation in advanced breast carcinoma
thR. Chaudhari , S. Singh, M. L. B. Bhatt, R. Gupta, K. Srivastava,
S. Gupta, R. Kumar
King George's Medical University, Lucknow, Uttar Pradesh, India, E-mail: [email protected]
Background: There are many trials which showed equal effect of hypofractionation as conventional fractionation (50 Gy in 25#) in early breast carcinoma. It includes Whealan trial, START-A and START- B trial. But there are no trials, showing the role of hypofractionation in advanced breast carcinoma. Aim: To compare effectiveness of hypofractionation with conventional radiotherapy in advanced breast carcinoma. Materials and Methods: Breast cancer patients with stage greater than IIa were registered in Department of Radiotherapy, King George's Medical University, Lucknow from January 2012-March 2013. Median follow up of 43 months. All these patients underwent modified radical mastectomy (MRM) with complete course of chemotherapy. External beam radiation therapy (EBRT) was given to all patients with Co-60 teletherapy machine. Dose was 50 Gy in 25# in conventional arm and 42.6 Gy in 16 in hypofractionation arm. Results: 12 out of 100 patients in conventional arm and 10 out of 100 patients in hypofractionated arm showed metastatic lesions. There is no significant difference in early and late toxicity. Conclusion: Hypofractionation schedule in advanced breast carcinoma yields similar results as that in early stage breast carcinoma. More studies of longer duration are required to establish the role of hypofractionation and to compare it with standard treatment for different variables. This analysis is of essence value in developing countries like India, where scarcity of resources are prevailing with major burden of disease.
Phyllodes tumor of the breast: 7 years data of demography, pattern of treatment and outcome from a single institution
thK. Naveen , A. Narayan, V. Nagarajan, M. Nagarajan, A. Rajkumar,
A. Raj, B. Sivanesan, M. Raj
GKNM Hospital, Coimbatore, Tamil Nadu, India, E-mail: [email protected]
Background: Phyllodes tumors are rare fibroepithelial breast tumors, with varying malignant potential ranging from completely benign to malignant forms. The main aim of this retrospective study is to evaluate the demography, pattern of treatment and outcome in patients with phyllodes tumor. Materials and Methods: Histopathology reports with phyllodes tumor reported between January 2009 to July 2015 were collected from Department of pathology. Clinical data of these patients were retrieved from medical records for evaluation. Results: Out of 75 patients with phyllodes tumor, 39 (52%) were benign, 4 (5.3%) borderline and 32 (42.6%) were malignant. The median age was 45 years (range of 14 to 65 years). With respect to size of the lesion, 4 (5.3%) had < or = 2 cm, 28 (37.3%) with 3-5 cm, 28 (37.3%) with 6-10 cm and 15 (20%) had more than 10 cm size. 40 patients (53.3%) underwent mastectomy while 35 patients (46.6%) underwent wide local excision. Among malignant phyllodes patients, four underwent adjuvant chestwall radiotherapy, one of whom failed locally. Two patients had metastasis at the time of presentation (both underwent palliative mastectomy). The median follow up was 6 months (range of 1-72 months) among malignant phyllodes patients, of whom six patients (18.7%) had recurrence: 3 local and 3 distant. Conclusion: More than half of the patients underwent mastectomy since the tumor size was larger which determined the type of surgery. The local failure rate was less than 5%.
Variations in target volume and organs at risk in whole breast three-dimentional conformal radiotherapy for breast cancer by various method of optimization of tangential technique
thS. Barik , C. Prakash, K. Sahni, M. Rastogi, S. P. Mishra, S. Farzana, N. Yadav
Ram Manohar Lohia Institute of Medical Sciences, Lucknow, Uttar Pradesh, India, E-mail: [email protected]
Background: Radiotherapy plays a mojor role in the management of breast cancer. In 3D-CRT for Whole breast one of the common techniques is tangential technique for adequate coverage of the target volume (i.e., Breast and Regional Lymphnodes) along with Supraclavicular field if required. Aim: In this study various parameters of tangential fields are optimized by changing the depth of normalization point in order to effect dose distribution. Materials and Methods: This study has been done on computed tomography images of 20 patients who has undergone Breast Conservation Surgery. All patients were simulated on CT Simulator without contrast and the target volume and the organ at risks were contoured. The Tangential Fields and the Supraclavicular fields were planned as indicated. The tangential fields were optimized with change of normalization point in four points: (1) Isocenter (Confluence of rotation gantry axis and collimator axis), (2) Middle of thickest part of breast or middle of inter field distance (IFD), (3) Border between the lung and chest wall and (4) Between IFD and isocenter. Dose distributions have been compared for all patients in different methods of the tangential field. The doses of the target volume and organs at risk were recorded for each normalization point and was compared. Results: In optimization of the tangential field all methods have similar coverage of PTV. Each method has spatial advantages and disadvantages. If it is important for the physician to reduce the dose received by the lung and heart, second method is suggested since in this method average and maximum received dose to heart and lung have been reduced few percent in comparison to other methods. If a better coverage of PTV is important for the physician fourth method can be an optimized method. In this method, average and maximum received dose to PTV have been increased few percent in comparisons of three other methods. If Dose to the heart is a concern then the physician should avoid the third method as mean dose to heart and V5 is slightly increased. Conclusion: In optimizing of tangential all methods are similar. Each method has special advantages and disadvantages. The physicians can change the depth of the normalization point in the breast to get the desired average dose. This can be a useful tool in centers who have limited recourses in form of technology and infrastructure.
Male breast cancer: Retrospective analysis from a tertiary cancer center
thY. Verma , V. Kaushal, A. Chauhan, R. Dhankhar, P. Kaur, R. Atri
Post Graduate Institute of Medical Sciences, Rohtak, Haryana, India, E-mail: [email protected]
Background: Though accounts for less than 1% of all malignancies in males, breast cancer seems out of the list of rare malignancies. Periodic reports of cases calls for considering protocols to be made for its management. Aim: To retrospectively analyze trends in male breast cancer as to its distribution, presentation, treatment and outcome. Materials and Methods: Twenty three patients of male breast cancer registered in Department of Radiotherapy, Pt. B.D. Sharma University of Health Sciences, Rohtak (India) during 2005-12 were analyzed retrospectively. Frequency distribution analysis of the demographic and clinico-pathological data and treatment variables was done. Results: Mean age of presentation was 60.5 years; range from 48-82 years. In all but one patient, chief complaint was lump breast. Either of the sides was almost equally affected with R: L ratio of 1.3:1. Average duration of complaint was 13.8 months (range 1-48 months). History of gynaecomastia was noted in 3 patients, significant benign prostate hypertrophy in 7 and hypertension needing medical treatment in 3 patients. Majority were smokers (19/23) and more than half alcoholic (13/23). One patient reported positive family history (similar disease in elder brother leading to death). Three patients had metastatic disease at presentation and received palliative treatment. Stage II patients were 26% (6/23), stage III were 61% (14/23) and stage IV were 13% (3/23). Node positive were 56.5% (13/23). Pathology was invariably infiltrative ductal carcinoma (IDC). Out of twenty patients of non-metastatic disease, six never reported back for treatment. In patients (4/14) receiving surgery and chemotherapy Tamoxifen (SC) mean event free survival was 33 months. In patients (2/14) receiving surgery and radiotherapy Tamoxifen (SR) mean event free survival was 45 months. In patients (8/14) receiving surgery, chemotherapy & radiotherapy Tamoxifen (SCR) mean event free survival was 52 months. Conclusion: Despite possibility of male breast disease being apparent at early stage, patients present with locally advanced disease. Radical surgery with adjuvant/neoadjuvant chemotherapy and adjuvant radiotherapy remains the gold standard.
Key words: Breast cancer, chemotherapy, male, radiotherapy, uncommon
Neoadjuvant chemotherapy comparing doxorubicin and cyclophosphamide versus dose dense doxorubicin and cyclophosphamide in locally advanced female breast cancer:
A prospective randomized trial
thA. P. Suresh , A. Basu, K. B. Choudhury, K. S. Manir, K. Ghosh,
A. Chakraborty, S. Ganguly
R. G. Kar Medical College and Hospital, Kolkata, West Bengal, India, E-mail: [email protected]
Background: Locally Advanced Breast Cancer (LABC) (AJCC TNM stage groupIIIA, IIIB, IIIC) is associated with high risk for distant relapse compared to early breast cancers, despite modern multimodality therapy. Neoadjuvant chemotherapy (NACT) plays an important role in downstaging initially unresectable tumours to operable disease. There are a large number of chemotherapy regimens tested in the neoadjuvant setting but the optimal regime remains unknown. Dose density improves clinical outcomes significantly but has seldom been tested in the neoadjuvant setting. Aim: To compare the efficacy, safety and tumour downstaging using two regimens of NACT with doxorubicin, cyclophosphamide-conventional three weekly and dose dense (two weekly) in LABC. Materials and Methods: In this prospective, randomized, parallel, open label single-institutional study, between January 2014 & March 2015, patients of biopsy proven LABC cT3-4N1-3M0 with normal baseline haematological, biochemical and cardiological parameters (LVEF≥50%) and ECOG PS0-1were randomised into two arms by computer generated random number sequencing to receive either Inj Doxorubicin (60 mg/m2) & Inj Cyclophosphamide (600 mg/m2) every 21 days for 4 cycles (Arm A; Control) or Inj Doxorubicin (60 mg/m2) & Inj Cyclophosphamide (600 mg/m2) every 14 days for 4 cycles with GCSF support (ArmB; Study). After completion of 4 cycles of NACT, response was assessed (RECISTv1.1) and the responders were sent for MRM. After MRM all patients were treated with adjuvant chemotherapy with Inj. Paclitaxel 175 mg/m2 every 21 days for 4 cycles. Adjuvant External Beam Radiotherapy (50 Gy/25#/5weeks) and/or adjuvant endocrine therapy were administered as indicated. Toxicities were assessed using CTCAEv4.0. Results: At a median follow up of 4.5 months, 61 eligible patients were analysed. The baseline characteristics were comparable in both the arms, with median age 47 yrs & 45 yrs (p = 0.67), 38.7 vs 60% premenopausal (p = 0.1) and 48.4 vs 56.7% ER+ (p = 0.5) in Arm A & B respectively. There was no significant difference in tumour downstaging after NACT between both arms with ycCR12.9 vs 6.7%; ycPR71 vs 80% (p = 0.8) & ypCR16.1 vs 10 (p = 0.9) in Arm A&B respectively. Grade 3 toxicities between both arms were also similar (neutropenia 19.4% vs 6.7% [p = 0.3], anaemia 16.1% vs 10% [p = 0.6], nausea vomiting 0% vs 6.7% [p = 0.26]). The mean PFS was 17.22 + 0.79 months vs 17.4 0.85 months. Conclusion: Although this study suffers from low sample size and short follow up, it demonstrates that both regimens are comparable in terms of efficacy, tumour downstaging & toxicities.
Body image and psychosexual issues among post mastectomy patients in Indian setting
thP. Rajmane , S. Shanmugakumar
Madras Medical College, Chennai, Tamil Nadu, India, E-mail: [email protected]
Aim: To study the psychosocial impact of mastectomy on body image and sexuality among breast cancer patients in Indian population. Background: Breast cancer and its treatment can have a significant physical and emotional impact on body image and significant negative impact on a woman and her relationships. Materials and Methods: The study group consisted of 142 patients who had undergone mastectomy at our institution during the period of 2008 to 2013. Following mastectomy, patients underwent adjuvant treatment in the form of chemotherapy, radiotherapy and hormonal therapy. The patients were disease free at the time of interview. The patients attempted a questionnaire consisting of 29 questions out of which 13 questions were related to psychosocial assessment, 11 to body image and 5 to sexual life. The questionnaire was constructed from questions regarding psycho social assessment and body image issues and validated by face validation through peers. Results: 45% study population comprised age >50 years. 80% were postmenopausal. 49% had good psychosocial scores. 39% had poor to fair body image scores. Only 47% had a good to normal sexual life post mastectomy. Decreased sexual desire was seen in 70%. 8% of the patients had experienced broken relationships after mastectomy. More than the mastectomy, hair loss was more distressing as the major body image issue among 60%. Awareness regarding artificial breast reconstruction was low seen in only 46%. Radiotherapy did not have an influence over psychological scores. Conclusion: Treatment for breast cancer is associated with intense psychological distress and sexual function deterioration. Hair loss was a major factor for body image deterioration. This may be attributed to the Indian ethnic wearing. Health professionals should assess these aspects especially in the younger sexually active patients for providing an improved quality of life along with improved survivorship.
Carcinoma breast with inguinal nodal metastasis: A rare case presentation
thC. Suji , S. Shanmugakumar, N. V. Kalaiyarasi, Baskar, Sundaresan, Prabagaran, Madhumathi, V. Karthick, S. Kumar
Madras Medical College, Chennai, Tamil Nadu, India, E-mail: [email protected]
Abstract: Breast cancer frequently metastasize to regional lymph nodes. Inguinal lymph node metastasis of breast cancer is very rare. This is the first report case of breast cancer diagnosed with inguinal lymph nodal metastasis in MMC. A 50 year old postmenopausal female presented with history of lump in the right breast and swelling in the right inguinal region. Physical examination revealed a lump in the right outer quadrant of the breast of size 4 * 3 cms and multiple nodes in the right axillary region largest measuring 1 cm. There is also a swelling in the right inguinal region of size measuring about 5 * 4 cms which is hard and fixed to the underlying structures. Mammogram revealed single ill defined predominately hypoechoeic lesion of size 4 cms with multiple malignant axillary lymph nodes largest measuring 1.2 * 0.6 cms, BIRADS 5. Fine needle aspiration cytology from the right breast iump was suggestive of ductal carcinoma with mucinous differentiation. CT abdomen with oral intravenous and delayed contrast was taken which showed a conglomerate right inguinal node measuring 5.3 * 4.6 cms and enlarged coeliac node measuring 1.6 * 0.8 cms. Ultrasound guided FNAC of right inguinal node was suggestive of metastatic ductal carcinomatous deposits with mucinous differentiation. All laboratory data including CEA, CA 15-3 and CA-125 were within normal limits. Regular and complete physical examination after surgery as well as prompt intensive treatment for high risk patients may have positive significance in the treatment of such type of patients. However a type of more reasonable and individualized treatment is warranted.
Response to neoadjuvant chemotherapy in relation to obesity in carcinoma breast patients
thP. Rajmane , S. Shanmugakumar
Madras Medical College, Chennai, Tamil Nadu, India, E-mail: [email protected]
Background: Obesity has been related as an important factor in the etiology of breast cancer. But whether it is related to response to treatment is not well understood. Aim: To evaluate the relation between body mass index and therefore obesity and the response to treatment in breast cancer patients in Indian setting. Materials and Methods: Case records of 124 patients with locally advanced breast cancers treated with neoadjuvant chemotherapy during the period of May 2013 to May 2015 were retrospectively analysed. The cases were studied according to the stage, hormonal status, chemotherapy received (number of cycles and the drugs given) and menopausal status. Based on BMI the patients were categorised into underweight, normal, over weight and obese according to the WHO criteria for obesity. Response was assessed according to the RECIST criteria. Results: The median age of presentation was 47 years. 60% of the patients were post menopausal. 35% were normal/under weight, 45% were overweight and 20% were obese. Patients received either four cycles of Inj. Paclitaxel or four cycles of inj. 5-fluoro uracil, inj. doxorubicin and inj. cyclophosphamide as neoadjuvant chemotherapy. Comparison was made based on the patients BMI. Overweight and obese patients had a less pCR. Conclusion: Increased BMI is associated with poor response to treatment in breast cancer patients. This indicates that obesity should be taken into account as a risk factor and greater attention should be given to consider aggressive treatment in these patients.
A rare case of bilateral carcinoma breast with two different receptor status
thM. K. Advait , S. Rawat, T. Pounikar
Netaji Subhash Chandra Bose Medical College, Jabalpur, Madhya Pradesh, India, E-mail: [email protected]
Background: 62 year old lady with negative family history of carcinoma breast presented with a lump in right breast for 6 months and an incidentally noted lump in the left breast during examination by the surgeon. Initial metastatic work up revealed USG and Chest -ray negative for any metastasis. Right breast lump measured 4.5 * 4 cm and the left breast lump measured 2 * 2 cm FNAC of both the lump were positive for invasive duct carcinoma. initially she underwent mrm of the right breast and fifteen days after she underwent mrm of the left breast post op right breast staging was T2pN2aMo and the left breast staging was pT2N1M0. Both the tumors were positive for invasive duct carcinoma grade 111. Her hormonal receptor status study revealed that right breast was positive for ER, PR and Her-2-neu equivocal and the left breast was ER, PR negative and HER-2-neu positive. HER-2-neu gene amplification by FISH was done and it was positive after undergoing bilateral mastectomy the patient received six fractions of chemotherapy with CEF, in view of the bilateral nature of the tumor. Post six fractions of chemotherapy she received she was planned to receive simultaneous breast irradiation to both the breast and she received 50 Gy to either of the breast after completing the irradiation the patient was started on hormonal treatment T. Anastrazole 1 mg od. Results: It has been almost one year she had finished irradiation and is on hormonal therapy, as the patient is under regular follow up till now there is no occurrence of any visceral or bony metastases. Conclusion: Women with a strong family history of breast cancer with multicentric tumor foci in one breast and insitu lobular carcinoma have a high incidence of bilateral breast carcinomas which might be synchronous or metachronous bilateral breast carcinoma are much frequent in BRCA1/2, PTEN and ATM families than in general population. B/L breast cancer represents relatively a small proportion of all breast cancers the incidence of synchronous breast cancer is 1-2% and that of metachronous is 5-10%. The prognosis of B/L breast cancer depends mainly on clinical stage and on length of interval between first and second cancer. The longer the women survived after the first cancer diagnosis, the greater is the likelihood of her developing a second cancer. It has been shown that survival also depends on the level of HER-2-neu expression. This is a rare case of ca breast as the hormone receptor status in either of the breast were different.
Assessment of radiation dose to the left anterior descending coronary artery in patients with left breast cancer
thD. K. Das , B. S. Yadav, N. Kumar, M. Singhal, N. R. Singh
Post Graduate Institute of Medical Education and Research, Chandigarh, India, E-mail: [email protected]
Background: During radiation delivery to the breast or chest wall, a part of the dose is also received by heart and other organs such as Left anterior descending coronary artery (LAD), lungs and contralateral breast. The aim of this study was to assess the radiation dose received by these organs in patients with left breast cancer. Materials and Methods: Total 30 patients, 15 each of breast conservation surgery (BCS) and mastectomy were taken and planning Computerised Tomography (CT) was done by giving 100 ml of intravenous (IV) contrast. Chest wall, whole breast, heart, lungs, LAD, proximal and distal LAD, and contralateral breast was contoured for each patient. Radiotherapy plans were made by standard tangent field. Dose prescribed were 40 Gy/16#/3 weeks to both chest wall and whole breast. Mean dose to heart, LAD, proximal and distal LAD, mean and V5 of right lung, and mean, V5, V10 and V20 of left lung, mean dose and V2 of contralateral breast were calculated for each patient and compared between BCS and mastectomy patients using student's T test. Results: Mean doses to the heart, LAD, proximal LAD, distal LAD, right lung, left lung, right breast and v2 of right breast were 3.347 Gy, 15.895 Gy, 3.353 Gy, 28.08 Gy, 0.295 Gy, 6.459 Gy, 0.376 Gy and 0.24% respectively for mastectomy patients. Mean doses to the heart, LAD, proximal LAD, distal LAD, right lung, left lung, right breast and v2 of right breast were 4.375 Gy, 15.22 Gy, 4.28 Gy, 25.58 Gy, 0.462 Gy, 10.7 Gy, 0.55 Gy and 1.43% respectively for breast conservation surgery patients. V5 of right breast for both mastectomy and breast conservation surgery patients is 0% and v5, v10 and v20 of left breast for mastectomy and breast conservation surgery patients were 17% and 21%, 15% and 18% and 13% and 15% respectively. Conclusion: There was no difference between dose received by heart, LAD, proximal LAD, distal LAD and left lung between breast conservation surgery and mastectomy patients. Distal LAD received significantly more dose than proximal LAD in case of both breast conservative surgery and mastectomy patients. Mean dose of opposite breast was significantly higher in BCS patients.
In audit of pathological respose following neoadjuvant chemotherapy with paclitaxel and trastuzumab in Her 2 Neu positive locally advanced carcinoma breast patients
thN. V. Vinin
E-mail: [email protected]
Background: Systemic therapy is an integral part of the multidisciplinary curative treatment of primary breast cancer and results in significant reductions in risk of recurrence and death. Primary induction chemotherapy has been evaluated in a number of studies in patients with breast cancer. Pathologic complete response (pCR) after preoperative therapy is a powerful surrogate of long-term diseasefree survival. It is hypothesized that a regimen that produces higher rates of pCR in the neoadjuvant treatment setting will also result in higher rates of long-term cure. Aim: To assess pathological response following neoadjuvant chemotherapy with paclitaxel and Trastuzumab in Her 2 neu positive locally advanced Carcinoma Breast patients. Materials and Methods: All patients of Her 2 neu positive locally advanced Carcinoma breast who received paclitaxel and trastuzumab as neoadjuvant chemotherapy during the period of August 2013 to August 2014 will be included in the study. This was be a retrospective audit. Pathological response will be graded according to AJCC criteria as complete response, partial response and no response. Results: Total of 20 patient details were analysed. Median age of patients were 49 years. Composite staging was done using AJCC seventh edition. Two patients were in Stage IIB, twelve were in Stage IIIA, five patients were in Stage IIIB and one patient was Stage IIIC. Ten out of total twenty patients ten out of total twenty patients had pathological complete response. That is 50% of patients had complete response. Rest of the 50% patients had partial response. Conclusion: In this audit we were able to find that 50% of Her 2 Neu positive locally advanced Carcinoma breast patients had pathological complete response with neoadjuvant chemotherapy with Paclitaxel and Trastuzumab. It is a known fact that pathological complete response after neoadjuvant chemotherapy is a surrogate marker for longterm diseasefree survival. Hence the results of this audit point towards Paclitaxel and Trastuzumab as a good option for neoadjuvant chemotherapy in Her 2 Neu positive locally advanced Carcinoma breast patients, if there are no other constraints.
An audit of clinical and pathological response following neoadjuvant chemotherapy with paclitaxel and carboplatin in triple negative locally advanced carcinoma breast patients
E-mail: [email protected]
Background Triple-negative breast cancer comprises 15% to 20% of breast cancers. It accounts for a disproportionate share of morbidity and mortality because of its aggressive behavior, increased incidence in younger women, and lack of effective targeted therapies. In India, the incidence of TNBC varies from 12.5% to 29.8%. Although there is no standard NACT regimen for TNBC, administration of both an anthracycline and a taxane, sequentially or concurrently, is warranted, even in patients with relatively early-stage disease and results in a pCR rate of 30% to 40%. Based on similarities of gene expression array patterns between BRCA1-associated and sporadic TNBCs and evidence of single-agent activity in BRCA-mutated cancers, there is a great deal of interest in studying the addition of platinum analogues to NACT in sporadic TNBC. Aim: To assess response (clinical and pathological) following neoadjuvant chemotherapy with paclitaxel and carboplatin in triple negative locally advanced Carcinoma Breast patients. Materials and Methods: All patients of triple negative locally advanced Carcinoma breast who received paclitaxel and carboplatin as neoadjuvant chemotherapy during the period of August 2013 to January 2014 were included in the study. Chemotherapy schedule given was Paclitaxel 80 mg/m2 plus Carboplatin AUC 2 weekly for 12 weeks. Clinical response was assessed by recording the size of the breast lump and/or axillary lymphedenopathy pre and post chemotherapy. Pathological response was graded according to AJCC criteria as complete response, partial response and no response. Results: A total of 11 patients were enrolled. Median age at presentation was 45 years. Seven patients had left sided tumor. Most common tumor stage was T3 and N1. IDC was the most common histology. Seven patients underwent Modified radical mastectomy and 4 patients had breast conservation surgery. Out of them 6 patients had clinically complete response at nodal and primary. Pathological complete response was seen in 6 (54%) patients. Conclusion: Since the pathological complete response is a surrogate marker for long term survival and also because of the lack of effective targetted therapies in TNBC, use of a regime which will increase response rates should be viewed with interest. But the total sample size in this study is very small. Future studies needs to be conducted to address this issue.
A phase II study of 2-weeks of adjuvant whole breast/chest wall and/or regional nodal radiotherapy in patients with breast cancer
thBudhi Singh Yadav
Postgraduate Institute of Medical Education and Research, Chandigarh, India, E-mail: [email protected]
Background: To report results in terms of feasibility and early toxicity of hypofractionated adjuvant whole breast/chest wall and/or regional nodal radiotherapy in patients with breast cancer. Materials and Methods: Between June 2013 and October 2014, 50 patients with breast cancer, post mastectomy or after breast conservative surgery (BCS) were included. The trial was approved by institutional ethics committee. Patients were planned on simulator with 2 tangential fields to breast/chest wall and incident supraclavicular fossa field. Radiotherapy dose delivered was 34 Gy/10#/2 weeks followed by a boost of 10 Gy/5#/1 wk in cases with intact breast. Acute skin toxicities were recorded during and after treatment according to RTOG acute radiation morbidity scoring criteria. The principle end point was of acute toxicities and cosmetic score analysis. Cosmetic outcomes were assessed before treatment and then on regular follow up. This trial is registered with ClinicalTrials.gov, number NCT01849133. We also did cost benefit analysis and compared with standard treatment of 35 Gy/15#/3 weeks. Results: Median follow up was 18 months (range 5-20 months). Mean age was 51 year (range 26-75). Left sided tumor was in 25 (50%) patients. TMAC was done in 40 (80%) and BCS in 10 (20%) patients. Acute grade 2 and 3 skin toxicity was seen in patients 16 (32%) and 1 (2%) patients respectively. Grade 3 skin toxicity was seen in skin fold in 3 (6%) patients. In patients with BCS, grade 2 subcutaneous toxicity and edema was seen in 1 (2%) patient each. Cosmesis was excellent/good in 8 (80%) and good/fair in 2 (20%) patients. In cost benefit analysis there was significant less financial burden on the patient with 2 weeks treatment. Conclusion: Hypofractionated radiotherapy in 2 weeks is feasible in patients with breast cancer and was associated with acceptable acute skin toxicity profile. Long term follow up is needed to assess late toxicity of radiotherapy and clinical outcomes. It also reduced the financial burden on the patient and family. Hypofractionation will help the radiation centers worldwide to meet the growing need for radiation in breast cancer, particularly in developing countries where resources are limited and patients have to travel for long distance for treatment.
Cautious 22 - factors affecting breast carcinoma in Northern India
thS. Agarwal , S. N. Prasad, S. Singh
J.K. Cancer Institute, Kanpur, Uttar Pradesh, India, E-mail: d[email protected]
Background: Breast cancer is the most frequently diagnosed cancer in women. There is considerable geographic, ethnic, and racial variability in breast cancer incidence. Ethnicity and national origin rank highly as predictors of risk for breast cancer with up to a 10-fold variation throughout the world. Materials and Methods: 2060 carcinoma Breast patients registered in J K Cancer Institute, Kanpur between January 2008 to July 2014 were retrospectively studied and various factors affecting the disease and its management were analysed. The various factors were then grouped into 3 categories namely Patient, Tumor & Management characteristics. Results: We found in our study: (a) Breast carcinoma seems to be increasing in younger women (0 to 45 years) of about 43%. (b) There is 62%addiction to tobacco. (c) Immunohistochemistry reveals: ER +ve PR +ve 68% ER +ve PR -ve 6% ER -ve PR +ve 3% Her2neu +ve 24% TNBC 20%. (d) About 16% of patients had history of pre-malignant conditions. (e) Only 9% of patients have been operated by an oncosurgeon. The rest were operated by General surgeon out of which 68% had residual disease at the time of re-evaluation. Conclusion: Breast cancer was found to be more common among post menopausal women of Lower middle SE status, aged b/w 41-60 years with parity more than 2. Most of the patients showed a characteristic of addiction to tobacco chewing which may warrant a larger sample size study to evaluate it as one of the risk factors. 16% of patients also showed a history of premalignant lesions like fibroadenosis, fibrocystic disease, duct ectasia Tumor was mostly lateralized to the left breast & the most common HP was IDC. 23.3% showed triple negative hormonal status which is considered to be a poor prognostic factor. From our study we also conclude that the quality of surgery being done can be a significant factor in the management of Breast Cancer.
Assessment of contralateral breast dose reduction in post mastectomy patients using superflab during external beam radiotherapy
thA. Solanki , A. Mayilvagnanan, H. Kumar
SP Medical College, Bikaner, Rajasthan, India, E-mail: [email protected]
Background : Breast cancer is the most common cancer in women worldwide. In India, breast cancer is reported as the most common cancer in women. External beam radiotherapy (EBRT) is used regularly in post operative breast cancer cases, to control locoregional relapses and thus increase survival rates. Present study is concerned about dose to contralateral breast (CLB) received during EBRT to breast cancer. This dose mainly results due to scatter from treatment head. Dose to CLB in five post operative breast cancers were evaluated using CaSO4-Dy thermoluminiscent dosimeter (TLDs). The effect of superflab placed over the CLB is also investigated for dose reduction. Superflab can effectively attenuate scattered radiation with low energies. Materials and Methods: Five postmastectomy patients were enrolled in this study. The patients received the treatment at Linear Accelerator (Varian Medical Systems, Model: 2300CD) by 6MV X-Rays. The dose schedule was 200 cGy/fr, 5 day a week for 5 weeks. CaSO4: Dy TLD discs (0.8 mm thick; 13 mm diameter) with enough sensitivity and reproducibility were selected for measurements. Calibration curves for all the discs were obtained by exposing them up to 10 cGy for 6MV X-Rays at dmax for 10x10 field size at solid water phantom of density 1.03 gm/cc, with 1 cGy interval. Prior to use discs were annealed for 1hr at 400oC. The TLD discs were placed on the CLB for dose measurement. Measurements were made for 5 fractions without bolus and with bolus for the next 5 fractions. The discs were read 24 hrs post-exposure in the TLD Reader (Nucleonix Corp) and the glow curves were obtained. The TL counts were obtained from area under the curve of the glow curve. The dose measured by the disc was estimated from the formula D = Mi, net x FC, Mi, net = Corrected by background of the ith disc, FC = calibration factor of ith disc. Results: The average dose received by the CLB without and with bolus is 5.78 +/- 0.98 cGy/# and 1.90 +/- 1.17 cGy/# respectively. This resulted in the average reduction of CLB dose by 40%-80%. Conclusion: Dose to contralateral breast can be reduced by 40-80% by using superflab. This is a convenient and less time consuming method. Its role in reduction of 2nd malignancy in opposite breast needs larger studies with longer follow up.
Co-relation of skin dosimetry with development of toxicity following accelerated partial breast irradiation using multi-catheter interstitial brachytherapy
thT. Wadasadawala , L. Gurrum, K. Joshi, A. Budrukkar, R. Phurailatpam, S. Paul, R. Sarin
Tata Memorial Centre, Mumbai, Maharashtra, India, E-mail: [email protected]
Background: The reporting of skin doses in multi-catheter interstitial brachytherapy (MIB) has not been practiced uniformly due to lack of clear consensus on the delineation of the skin contour as well as reporting of the various dose volume statistics. Aim: To evaluate skin dose volume effects with respect to acute & late skin sequelae. Materials and Methods: 42 eligible patients who underwent 3D CT based planning on Oncentra treatment planning system for accelerated partial breast irradiation with MIB were included for the analysis. The patients were treated from November 2011 to December 2014 and had a median follow up of 24 months. Various skin structures were contoured over the ipsilateral breast: Skin with internal depth of 2 mm, 3 mm, 4 mm, 2 mm internally & 2 mm externally, 2 mm external only (skin surface). Dose 0.1 cc, 0.2 cc, 1, 2, 5 cc & V33, V50, V66, V100 received by each skin structure were calculated. The first analysis involves correlation between each dose and volume metrics amongst the various skin structures which was calculated using Pearson's coefficient. Second analysis studied the correlation between the doses received by various skin structures to the development of skin sequelae as analysed by the Kruskal Wallis test. A p value of < 0.05 was considered significant. Results: Skin structures at various depths showed a consistent correlation (co-relation coefficient 0.33-0.98) with the calculated dosimetric indices (i.e., D0.1 cc, 0.2 cc, 1 cc, 2 cc & 5 cc). Poorer correlation (coefficient 0.17 to 0.22) was observed with the volumetric indices (e.g., V50 of skin 2 mm depth and V100 of skin 3 mm depth, 4 mm depth, skin 2 mm internally & externally, skin 2 mm external only to D0.1 cc, 0.2 cc). However, the development of acute complications (infection or wound gape) was significantly correlated to V100 of skin 2 & 3 mm internal depths (p - 0.03 & 0.04 respectively), V50 of skin internal & external (p - 0.04) & dose received by 5 cc of skin surface (p - 0.03). Four patients developed wound gape of which 1 patient developed ulcer which healed with antibiotics & 1 patients developed infection of seroma. It was observed that none of the volumes showed a significant association with the cosmetic outcomes (including cosmesis at last follow up or change of cosmesis over time) and skin changes including fibrosis. Conclusions: Volumes of skin 2 & 3 mm internal depths getting 100% of the dose & skin surface doses are crucial for development of acute sequelae.
A comparative study of radiation induced skin reactions with hypo-fractionation versus conventional fractionation in post-mastectomy irradiation
thR. Purohit , N. Sharma, H. Kumar, P. Murali, R. Kumar
Acharya Tulsi Regional Cancer Treatment and Research Centre, Bikaner, Rajasthan, India, E-mail: [email protected]
Background : Due to its advantage in local tumor control and overall survival benefit, radiotherapy remains an important part of adjuvant treatment of invasive breast cancer. Various prospective trials have found hypo-fractionation (HF) schedule to be safer and effective in long term follow-up. The HF accelerated schedule of 40 Gy in 15 fractions has already been adopted by many centers in India. With the increasing patient load on the radiotherapy machines and the lack of compliance to the 5-6 weeks long treatment schedule of conventional fractionation (CF), there has been a growing interest in adopting the newer HF options. The patients are very much concerned about the cosmetic appearance and reactions due to radiation. Aim: To compare the acute skin reactions in the two above mentioned radiotherapy schedules in post-mastectomy irradiation. Materials and Methods: 100 invasive breast cancer patients after modified radical mastectomy and adjuvant chemotherapy registered from January 2014 to December 2014 were enrolled for the study. 50 patients were randomly assigned to either arm. The patients in the CF arm were treated with 50 Gy in 25 fractions over 5 weeks with 2 Gy per fraction. The patients in the HF arm were treated with 40 Gy in 15 fractions over 3 weeks with 2.66 Gy per fraction. The skin reactions were assessed (by CTCAE) weekly during the treatment and then after one month. Results: Overall acute skin reactions were found to be higher among the patients in CF arm (88%) as compared to HF arm (68%) and the difference was significant (p value = 0.04). As far as moderate to severe skin toxicity was concerned, grade 2 reactions were seen in 42% patients in CF arm as compared to 22% in HF arm (P value = 0.01). Grade 3 skin reactions were seen in 16% patients in CF arm as compared to 6% patients in HF arm (P value = 0.03). 2 patients in the CF arm had interruption in the treatment. Overall treatment time in CF arm was 37 days as compared to 23 days in HF arm. The peak reactions occurred during last 2 weeks of CF. The reactions peaked after the completion of treatment in HF arm and were managed more conveniently. Conclusion: A significant reduction in skin reactions particularly grade 2 & 3 was achieved with treatment by accelerated hypo-fractionation, also reducing the overall treatment time by 2 weeks. It is an effective measure to improve compliance, manage machine load and reduce hospital stay.
Primary neuroendocrine carcinoma of breast: A case report
thK. L. Jayakumar , M. M. Abraham
Trivandrum Medical College, Trivandrum, Kerala, India, E-mail: [email protected]
Background: Primary neuroendocrine carcinoma of the breast is a rare histological subtype. According to the WHO classification of breast cancers, the diagnosis relies on (i) presence of morphologic neuroendocrine features, and (ii) neuroendocrine markers expressed in more than 50% of tumor cells. Primary neuroendocrine carcinoma in breast cancer is very rare and less than 100 cases have been reported in literature world wide. Case Report: We report the case of a 52 year old lady who presented with a lump in the breast. Mammogram was suggestive of a BIRADS 5 lesion in the upper outer quadrant with a clinical T1 size. She underwent a lumpectomy with axillary dissection. Histopathology revealed a tumor with neuroendocrine differentiation and one of the resected margins were positive. She underwent a Modified Radical Mastectomy and the pathological staging was pT2N0 with only a microscopic focus of tumor in the MRM specimen. Majority of the cells were diffuse positive for Chromogranin and Synaptophysin and for ER and PR. Whole body CT scan didn't show any other focus of primary or metastasis. She has been started on chemotherapy and is planned for chest wall irradiation and hormonal therapy. Discussion: Primary neuroendocrine carcinoma of breast presents a prognostic and therapeutic dilemma in that there are no clear established guidelines. Chromogranin A and Synaptophysin have been considered as the most sensitive and specific neuroendocrine markers in diagnosis. Various studies place the incidence as high as 5% of all breast carcinomas but these are mostly tumors with a focus of neuroendocrine differentiation and the incidence of pure neuroendocrine carcinoma of breast is less than 0.5% of all breast cancers. Prognosis for tumors with neuroendocrine differentiation is related to conventional histological tumor grading and staging, but not to the neuroendocrine differentiation per se as per most of the studies, with conflicting reports of better or worse prognosis. Conclusion: Pure primary neuroendocrine carcinoma is a rare entity with unknown prognostic and therapeutic implications.
Histopathological and clinicoepidemiological determinants of scarff Bloom Richardson grade and Nottingham Prognostic Index in carcinoma breast: Cohort study from eastern India
thS. Mishra , A. Das, D. Samanta, S. Senapati, R. Mallik 1 , S. Das 2
A.H. Regional Cancer Centre, 1 Patholab, Cuttack, Odisha, 2 CMC, Vellore, Tamil Nadu, India, E-mail: [email protected]
Background: Despite the improvement in multimodality treatment, the therapeutic outcome in carcinoma breast varies due to different prognostic and predictive factors. Aim: To present the epidemiological and clinicopathological features with Nottingham Prognostic Index (NPI) and Scarff-Bloom-Richardson (SBR) grading of a large cohort of carcinoma breast patients presented to a tertiary care hospital in eastern India. Materials and Methods: Data of 1658 patients of breast cancer from 2008 to 2013 were collected retrospectively. NPI and SBR grading was determined and influence of various clinicopathological features were analysed by univariate and multivariate regression analysis. Results: Mean age was 46.9 yrs. T size was - 5.7% T1, 65.9% T2, and 28.3% T3. Tubule formation was mild in 52.11%, moderate in 5.79% and severe in 0.9% of the patients. Nuclear atypia was intermediate 60.5%, severe29.4%, mild 2.17%. Moderate mitotic activity was observed in 63%, severe 20.32% and mild 8.5% patients. SBR Gr. I, II, III were 3%, 54.3% and 34.62%respectvely. Incidence of multicentricity, perineural invasion, vascular invasion and extra nodal extension were 6.3%, 5.9%, 40.5% and 22.6% respectively. Surgical margin was close or +ve in 21.4% of patients. Node -ve, Nodal Ratio <20% and >20% were 36.6%, 25.5% and 37.8% respectively. On univariate analysis, margin status, T-size and percentage of nodal involvement, tubule formation, perineural invasion, nuclear atypia, grade and mitotic activity and in multivariate analysis Tumor size, nodal ratio and nuclear atypia were significant prognostic features that influenced NPI. SBR grading was independent predictor of larger T size (Grade 1: 3.2 cm, grade II: 3.7 cm and grade 3: 4.2 cm, p < 0.05, n = 1423, univariate analysis) and higher nodal ratio (Grade 1: 9.6, grade II: 29.2 and grade 3: 29.7, p < 0.05, univariate analysis, n = 1496). Patients with younger age had higher BRS grade (Grade III: 46 yrs vs. grade I 50 yrs, p < 0.05, n = 1522). In multivariate analysis T size, and surgical margin were independent predictors for worse BRS grade. Conclusion: In India patients of carcinoma breast present at an earlier age with advanced stage. Nuclear atypia instead of tumor grade correlates with NPI in multivariate analysis whereas T size and surgical margin were independent predictors for worse BRS grade.
Intensity modulated radiotherapy with simultaneous integrated boost to lumpectomy cavity in breast conservation therapy:
A feasibility study
thB. Devnani , S. Sharma 1 , S. Rawat 1 , A. Pahuja 1
All India Institute of Medical Sciences, 1 Rajiv Gandhi Cancer Institute and Research Center, New Delhi, India, E-mail: [email protected]
Background: Radiation therapy (RT) is an integral component of breast conservation therapy. With conventional RT, time required for completion of radiotherapy is 6-7 weeks in women requiring an additional boost. Intensity modulated radiotherapy with simultaneous integrated boost (SIB-IMRT) is a technique which has ability to treat a boost volume simultaneously with the initial volume resulting in reduced treatment time. This prospective analysis has been performed to assess the feasibility of SIB-IMRT technique. Aims and Objectives: To analyse the acute toxicity profile and cosmetic outcome by using SIB-IMRT to lumpectomy cavity after breast conservation surgery. Materials and Methods: 32 newly diagnosed stages I-III breast carcinoma patients treated with SIB-IMRT after conservation surgery between May 2011 and September 2012 were included in this study. The target volume and organs at risk were contoured according to Radiation Therapy Oncology Group (RTOG) contouring guidelines. The fractionation used simultaneously delivered 1.8 Gy to the planning target volume (PTV) breast and 2.14 Gy to the resection cavity, yielding a dose of 50.4 Gy to PTV and cavity dose 59.92 Gy in 28 fractions. Patients were evaluated for acute toxicities by Common terminology criteria for adverse events (CTCAE) -version 4 and by Harvard breast cosmesis grading scale for cosmetic scoring. Results: Median age of patient was 48 years (29-70 years). Stage wise distribution of patient was 2, 27 and 3 for stage I, II and III respectively. The median PTV of breast was 1598 cc (range, 1040-2960 cc). The mean dose received by 95% resection cavity was 59.82 Gy. Mean volume receiving dose of >107% was 4.71%. The median mean heart dose was 12.75 Gy (6.1 Gy for right and 16.3 Gy for left sided tumors). The median duration for completion of radiation was 40 days. Median follow-up was 30 months. Acute skin toxicity was grade 1 in 56% of cases, grade 2 in 41% and grade 3 in 3%. At 6 months, cosmesis was excellent-good in 88% and fair in 12% patients. At 24 months, cosmesis was excellent in 57% and good in 43% patients; none of the patient had fair/poor cosmesis. Local control was 100% at the time of last follow up. Conclusion: SIB-IMRT technique in breast carcinoma is feasible with a favourable acute toxicity profile and good or excellent cosmesis at 24 months. Further follow up and studies with larger sample size would further better define the role of SIB-IMRT in breast cancers.
Primary neuroendocrine tumour of the breast: A rare entity
thA. Bhavani , S. Bhattacharjee, R. Arun
HCG, Bengaluru, Karnataka, India, E-mail: [email protected]
Neuroendocrine tumors are rare, slow-growing tumors derived from neuroendocrine cells, which are present throughout the body; they arise most commonly in the bronchopulmonary system and gastrointestinal tract. Neuroendocrine tumors of the breast are rare, accounting for less than 0.1% of all breast cancer and less than 1% of all neuroendocrine tumors. They pose a challenge to the medical fraternity in terms of diagnosis & therapy. Hence we present our experience by reporting a case of primary neuroendocrine tumour of the breast in a 60 years old female, its diagnosis & management.
Correlation of ER, PR receptor status and Her2-neu expression with histopathological findings and metastases in carcinoma breast
S.Mohanty, A. Tripathy, S. Mishra, A. Das, D. Samanta, S. Padhi, N. Panda, S. Senapati
A.H. Regional Cancer Centre, Cuttack, Odisha, India, E-mail: [email protected]
Background: Carcinoma breast is the most common cancer in India accounting for 25-31% of the cancer burden and the most common cause of cancer related deaths. Prognosis and treatment of patients with carcinoma breast depends on ER, PR receptor status and HER2-Neu expression along with histopathological factors like tumor size, grade, lymph node, NPI and stage to correlate and guide in stratifying the patients and their treatments. Aim: The current study was undertaken to find out any correlation between various histopathological parameters, ER, PR receptor status, HER2-Neu expression and metastasis in breast cancer. Materials and Methods: 178 patients with breast cancer were analyzed retrospectively from institutional records during the study period from January 2014 to January 2015. Data are analyzed using SPSS version 21 to correlate different parameters like age, stage, NPI, grade of tumor, receptor status, and metastasis. Results: Though 40 to 50 years is the most common age group (37.1%), prevalence in the 30 to 40 years age group is comparable (33.1%). Maximum numbers of patients are in stage IIA (27.5%) followed by stage IIIA (23%), IIIC (21.9%), and IIB (19.7%) respectively. 64.6% of the patients had grade 2 malignancy followed by grade 3 (30.89%). NPI ≥5.4 which is a poor outcome indicator accounted for 48.3% of the total cases followed by NPI 3.4 to 5.39 (39.3%). Majority of patients (45.5%) had triple negative receptor status and 23.5% of total patients had both triple negative receptor status and poor NPI. ER, PR negative HER2-neu expression is seen in 16.8% of total patients. In moderate NPI group, triple negative receptor status is frequently observed followed by ER, PR negative HER2-neu expression. 18.1% patients had both ER, PR receptor positive HER2-neu negative and had good NPI. Distant metastasis was seen in 26.4% of total patients and bone was found to be the most common metastatic site (38.98%). Amongst the metastatic breast cancer patients, 44.6% were found to have triple negative receptor status and 74.4% had poor NPI. Conclusion : From this retrospective study it is concluded that there is a rising trend in incidence of breast cancer in younger age group (<40 years). Most of them present with advanced stages of disease. Moderate and poor NPI subgroups have triple negative receptor status followed by ER, PR negative and HER-2-neu expression. Bone is the commonest metastastic site and most of the metastatic breast cancer patients had poor NPI.
A study to compare the outcome of hormone receptor positive and negative patients with HER-2 neu positive carcinoma breast:
A prospective study in a retrospective cohort
thD. Acharya , P. Pal, D. Pal, D. Narayanaswamy
Institute of Postgraduate Medical Education and Research, Kolkata, West Bengal, India, E-mail: [email protected]
Background: Breast cancer is a multifaceted disease comprised of a varied spectrum of clinical, pathologic and molecular features with different prognostic and therapeutic implications. Recent attention has been directed at molecular classifications of breast cancer. Targeted therapy in the form of Endocrine and Trastuzumab therapy for tumours expressing estrogen receptor/progesterone receptor (ER/PR) or human epidermal growth factor receptor 2 (Her2) proteins, respectively has significantly improved the outcome. Current studies showed that those tumours expressing hormone receptors has a better disease control than those not expressing hormone receptors. In this observational study we compared the outcome of treatment in Her2+, ER/PR+ and Her2+, ER/PR- breast cancer groups. Aim: Comparison of disease free survival (DFS) among Her2+, hormone receptor positive group and Her2+, hormone receptor negative. Secondary Aim: (1) Comparison of Toxicity among Her2+, ER+/PR+ group and Her2+, ER-/PR- group. (2) Comparison of overall survival (OS) among Her2+, ER+/PR+ group and Her2+, ER-/PR- group. Materials and Methods: Data of 61 histologically proven breast cancer patients, who have completed anti-Her2 therapy between Jan 2014 to Jun 2015, was collected from hospital records. 28 are Her2+, ER/PR+ and 33 are Her2+, ER/PR-. Analysis was done for those who received Inj. Trastuzumab (8 mg/kg loading, 6 mg/kg maintainance, q21d) for at least 9 cycles in addition to surgery, chemotherapy and/or radiotherapy. ER/PR+ group are also receiving Selective Estrogen Receptor Modulator (SERM) or Aromatase Inhibitor (AI) following completion of chemotherapy. An interim analysis of DFS, OS and toxicities of these patients was done by using appropriate statistical tests. Results: The median follow up period was 8 months. Out of these 61 patients, 57were alive at the time of analysis. The OS was similar in both arms. The DFS is also similar in the hormone receptor positive group compared to the negative group. Thus we could not find any statistically significant difference in DFS, OS and toxicities in both the groups. Conclusion : Even though we could not find any difference in this interim analysis, the longer follow up is necessary for come to a definite conclusion.
Pattern of care and survival in older women with breast cancer: A retrospective study
thD. Kishan , J. Gaur, V. Raturi, A. Batra, M. Saha
King George's Medical University, Lucknow, Uttar Pradesh, India, E-mail: [email protected]
Background: The elderly represents the large population of women with carcinoma breast, however there is lack of information regarding breast cancer care in the elderly. Aim: To determine the pattern of care and survival in older patients with breast cancer. Materials and Methods: The study population included 190 women aged ≥60 years with breast cancer treated between 2007 and 2015. Analysis was done for surgery, radiotherapy (RT), chemotherapy and hormonal therapy. Outcomes studied were locoregional recurrence (LRR), distant metastases, disease-free survival (DFS) and overall survival (OS) using univariate and multivariate analyses. Kaplan-Meier method was used to estimate DFS and OS. Results: Mastectomy was done in 169 (89%) patients and conservative breast surgery (CBS) only in 21 (11%) patients. Majority of the patients received adjuvant RT 157 (82.5%). Chemotherapy was given to 57 (30%) patients and hormones to 171 (89.5%) patients. LRR with or without distant metastases was 9% and distant metastasis rate was 22.3%. DFS at 8 years was 65%. With RT, DFS was 74% in patients aged <65 years and 71% in aged ≥65 years (p = 0.13). It was 71 and 82%, respectively, with chemotherapy (p = 0.041). DFS with hormones was 92% in patients aged ≥65 years and 76% in aged <65 years (p = 0.028). The OS was 76% at 8years. RT improved OS in all patients. OS with chemotherapy was 91% in patients ≥65 years, and 81% in patients <65 years (p = 0.044). With hormonal therapy OS was 93% in patients aged ≥65 years and 77% in patients <65 years (p = 0.03). Conclusion: CBS rate and chemotherapy use is very low in elderly women with breast cancer in India. Adjuvant RT, chemotherapy and hormonal therapy offered a therapeutic advantage in these patients.
Prospective study to compare acute reactions following hypofractionated radiotherapy vs conventional radiotherapy in carcinoma breast
thS. Kumar , S. N. Prasad, S. Singh, P. Shukla, J. Verma, P. Singh,
J.K. Cancer Institute, Kanpur, Uttar Pradesh, India, E-mail: [email protected]
Background: The standard radiotherapy schedule for chest wall irradiation post mastectomy is 50 Gy in 25#. However hypofractionated radiotherapy is hypothesised to be at least as safe and effective as standard treatment. We tested two dose schedule of 15 fraction and 25 fraction. Aim: To compare acute reactions between two dose schedules. Materials and Methods: Patients with histopathologically proven breast cancer were selected from opd of J.K. Cancer Institute and randomised in two arms to compare acute reactions after completion of radiothearpy. Arm A-40 Gy in 15 fractions over three week Arm B-50 Gy in 25# over five week. Results: We observed that patient in Arm A have skin reactions grade II, III lesser in grade than in Arm B grade III, IV. Reactions developed in Arm A was easily manageable with treatment while in Arm B ~30% patients required treatment break due to skin reaction. Conclusion: In term of reaction Arm B have more grade III/IV reactions required treatment breaks as compared to Arm A.
Correlation of molecular subtypes of breast cancer with histopathological staging: Our institutional experience
thM. Shah , S. Gupta, R. Shankar, S. Srinivasan, P. Chaudhary,
R. Agarwal, S. De, S. Agarwal
Pushpanjali Crosslay Hospital, Ghaziabad, Uttar Pradesh, India, E-mail: [email protected]
Background: Breast cancer is the most common cancer in women. Immunohistochemistry based classification of both ER/PR and HER-2/neu status provides prognostic and therapeutic benefit in these patients. This study attempts to identify the relationship of ER, PR, Her 2 neu, Ki-67 with age, laterality, tumor size and nodal status of the patient. Materials and Methods: 47 breast cancer patients treated between 2012 to 2015 at our institute were included in the present study. Data was analyzed with respect to ER, PR, and Her-2 neu status and, Ki 67 expression. Patients were classified on molecular basis into subtypes luminal A (ER+ and/or PR+/-, HER2+/-, Ki-67<14%), luminal B (ER+ and/or PR+/-, HER2+/-, Ki-67>14%), basal like (ER-, PR-, HER2-), and Her2/neu enriched (ER-, PR-, HER2+). Correlation of the molecular subtypes was done with respect to laterality, tumor size and nodal status. Results: 35 (74.4%) patients were in 40-60 years of age group, 8 (17%) in > 60 years and 4 (8%) in <40 years of age group. 25 (53%) patients were of right and 21 (44%) were of left side breast. The most common molecular subtype was luminal B in 48.9%, luminal A 10.6%, Her-2/neu enriched 17% and basal-like 23.4%. Lymph node involvement (82.6%) was most common in Luminal B subtype followed by Her-2/neu enriched. Most common tumor size was T2 in all the subtypes. T3 tumor size was seen most commonly in luminal A type (40%) followed by luminal B type (26%). Conclusion: As the traditional histological classification are not able to evaluate the biological behavior of the different breast tumors, molecular classification of breast cancer provide both therapeutic and prognostic information. Different immunophenotypes respond differently to different therapies. The use of IHC in breast cancer has become an integral part of a complete and comprehensive histopathology report. In terms of prognosis and prediction of response to treatment, in addition to histological grade and tumor sub type, hormone markers - ER/PR and HER-2/neu and Ki-67 have become the mainstay requirement for the oncologist.
Volumetric and dosimetric changes during deep inspiration breath hold technique for postmastectomy radiotherapy in left sided breast cancer patients
thP. Archana , A. Narayan, C. Jegan, V. Nagarajan, M. Nagarajan,
GKNM Hospital, Coimbatore, Tamil Nadu, India, E-mail: [email protected]
Introduction: DIBH has been shown to reduce the heart and lung dose in patients receiving RT for left sided breast cancer after breast conservation surgery (BCS). However the evidence in a post mastectomy (MRM) setting is minimal. Since many early stage breast cancers are being treated with MRM in our setting, we evaluated the volumetric and dosimetric changes of deep inspiration breath hold (DIBH) technique for post MRM radiotherapy in left sided breast cancer patients. Materials and Methods: Ten left sided post MRM patients were included in the study. For each patient, two 5 mm thickness non contrast CT scans were acquired, one in free breathing and one in deep inspiration breath hold position after immobilisation in a supine position on breast board with both the arms lifted above the head. Organ delineation was done as per RTOG guidelines. For each scan, 3D-CRT treatment plan with field-in-field technique was generated. The resulting dose volume histograms (DVH) were calculated. The volumetric changes and the doses received by the heart, lung and left anterior descending artery (LAD) were assessed. A p-value < 0.05 was considered statistically significant. Results: DIBH plans demonstrated 42% increase in the mean total lung volume and left lung volume compared with the FB plans (p < 0.001). The left lung mean dose (15 Gy vs 11.6 Gy), V20 Gy (28% vs 22%), V10 Gy (34% vs 26%), V5 Gy (46% vs 34%) also showed significant reduction in the DIBH plans compared to FB plans, while maintaining similar PTV coverage. Right lung mean dose (0.27 Gy vs 0.17 Gy) was also significantly reduced in the DIBH plans. There was significant reduction in the heart mean dose (6.7 Gy vs 5.3 Gy), V30 Gy (10% vs 7%) in the DIBH plans compared to FB plans. No statistical difference was seen in LAD mean dose (38 Gy vs 35.95 Gy) and Dmax 0.2 cc (50.87 Gy vs 50.48 Gy). There was an insignificant increase in the maximum dose received by the right breast (10.41 Gy vs 13.10 Gy). Conclusion: DIBH technique significantly increased lung volumes and reduced the dose to the heart and the left lung compared to the FB technique while maintaining similar PTV coverage. However, there was not a significant decrease in the mean LAD dose during chest wall irradiation.
Use, acceptance, efficacy and drawbacks of complementary and alternative medicine amongst breast cancer patients
thM. Barthwal , M. L. B. Bhatt, R. Gupta, K. Srivastava, S. Gupta,
R. Kumar, S. Singh, D. Tiwari
King George's Medical University, Lucknow, Uttar Pradesh, India, E-mail: [email protected]
Background: Interest in Complementary and Alternative Medicine (CAM) has grown dramatically over the past several years in cancer patients. Cancer patients are always looking for new hope, and many have turned to non-traditional means. This study was conducted to determine the prevalence of CAM in Breast cancer patients and what if any agents are being used (benefits and delay in treatment). Aim: To estimate the prevalence, benefits, drawbacks and common modes of CAM in Breast Cancer patients. Materials and Methods: Histologically proven, adult (above 18 yrs) Breast Cancer patients attending Radiotherapy outpatient department with history of use of CAM in any form, were included in the study. Face to face interview using a questionnaire was conducted after an informed written consent, including 128 patients. Results: The most commonly noted CAM therapies throughout the study include vitamins/minerals, herbal medicines and remedies together with homeopathy, medicinal teas, spiritual therapies, relaxation techniques, mind-body approaches (meditation, relaxation, and other imagery techniques), dietary approaches and food supplements, Chinese medications, botanical preparations, homeopathy, and spiritual healing. The mean age of participants was 47 years (ranging from 27 to 72 years). Data suggest that CAM is popular among cancer patients with 74% using some form of CAM. It was reported that among the CAM users; 42% noticed some kind of benefit in symptom, 19% did not noticed any benefit, while 39% noticed worsening of symptoms. Conclusion: It is imperative that health professionals explore the use of CAM with their cancer patients, educate them about potentially beneficial therapies in light of the limited available evidence of effectiveness. In addition, CAM usage was more common in breast cancer patients with poor emotional and financial status. The use of CAM may cause delay in definitive therapy.
A new scoring system for predicting recurrence risk in T1, T2 breast cancer with 1-3 positive axillary nodes postmastectomy: A guide for adjuvant therapy
thS. Gudi , T. Wadasadawala, A. Rishi, R. Sarin, A. Budrukkar,
V. Parmar, S. Gupta, T. Shet
Tata Memorial Hospital, Mumbai, Maharashtra, India, E-mail: [email protected]
Background: Role of Post mastectomy Radiotherapy (PMRT) in early breast cancer with 1-3 positive axillary nodes treated with Modified Radical Mastectomy (MRM) and optimal adjuvant systemic therapy is still controversial. Hence there is a need to identify subgroup of patients who have sufficiently high risk of disease recurrence to benefit from PMRT. Aim: To evaluate clinical outcomes of patients post-mastectomy having pathological T1-2 tumors with 1-3 positive axillary lymph nodes. Identify the risk factors for loco-regional recurrence as well as disease free survival so as to develop a scoring system for predicting outcome. Materials and Methods: Data collected retrospectively from eligible patients from 2005 to 2011. Kaplan Meir survival analysis was done for local control as well as disease free and overall survival. Various known clinical and pathological risk factors were correlated with outcome using univariate and multivariate analysis. Results: Total of 302 patients with median follow up 42 months were considered eligible. 5 year OS was 93.5% and DFS was 83.3% (Can run it for local control?). Tumor Grade (I/II versus II/III), Tumor size (≤3 cm versus >3 cm) ER status (positive versus negative) and Lymph node ratio (≤10% versus >10%) were significant factors predicting disease free survival. Age, no of positive lymph nodes (1 versus 2-3), lymphovascular emboli, HER2neu status and perinodal extension did not significantly affect outcome. Scoring with Cambridge index was also not found to be significant. Based on these factors a scoring system ranging from score 3-8 was developed. Patients with Scores 3-5 had significantly superior DFS when compared to those with scores 5-8 (p = 0.008). Conclusion: T1, T2 breast cancer with 1-3 positive axillary nodes post mastectomy and having multiple high risk factors should be strongly considered for PMRT. However, the new scoring system proposed merits independent validation in different cohorts with similar disease characteristics.
Dosimetric comparison of two different external beam whole breast irradiation techniques
thK. Bhadra , K. Talaptra, P. Shaju, D. Sharma, P. Chadha, M. Nadkarni
Kokilaben Dhirubhai Ambani Hospital, Mumbai, Maharashtra, India, E-mail: [email protected]
Aim: The aim of this study was to compare the dosimetries of two different external beam whole breast radiotherapy planning techniques: Three dimensional conformal RT (3D-CRT), and field in-field intensity-modulated RT (FiF-IMRT). In addition, we aimed to correlate the physical characteristics of the patients with treatment modalities. Materials and Methods: Twenty patients were included in the study. All the patients had early stage breast cancer and conserving surgery had been performed. Plans with two techniques were generated for each patient. Dosimetric comparisons were conducted, and correlations with patient characteristics and dosimetric outcomes were also analyzed. Results: FiF-IMRT was found to be the superior technique with a better homogeneity in the breast (DHI = 19.4%; P = 0.362 when compared to 3D-CRT). Regarding hot spots FIF IMRT was definitely superior to 3DCRT (PTV107 was significantly lower). When compared according to patient characteristics, the FiF-IMRT planning is overall better for all subgroups, but the DHI correlated with increased breast volume. While FiF-IMRT achieves better DHI in the breast, it has little effect on heart and lung doses. The Coverage index was better in FiF-IMRT group and also Monitor Units were less. Conclusions: Compared with 3DCRT FiF-FPIMRT proved to be a simple and efficient planning technique for breast irradiation. It provided dosimetric advantages, significantly reducing the size of the hot spot and minimally improving the coverage of the target volume. In addition, it was felt that FiF-FPIMRT required less planning time and easy field placements.
Hypofractionated radiotherapy versus conventional radiotherapy: Is there a difference in loco-regional recurrence rate when used in unselected breast cancer patient population in a tertiary care academic centre
thR. Yadav , P. Lal, S. Agrawal, M. Verma, S. Misra, S. K. Senthil Kumar, K. J. Maria Das, S. Kumar
Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India, E-mail: [email protected]
Background: Randomized trials have established the role of hypofractionated radiation therapy (HFRT) in early breast cancer. HFRT allows for less costly and more accessible treatment. However, there is paucity of data for HFRT in locally advanced breast cancer (LABC). We report the impact of HFRT in unselected breast cancer patients (all stages except metastatic, both BCS/MRM) and compared with CFRT for any differences in outcomes. Materials and Methods: 463 patients of BCS/MRM treated between January 08 and July 13 with CFRT (50 Gy/25 fr) or HFRT (42.4 Gy/16 fr or 40 Gy/15) to the breast/chest wall (CW) SCF Ax, treated in 2 time periods were retrospectively reviewed. RT was given by direct electron field/bitangential photons to the CW and by latter to the breast. SCF Ax RT was given by enface photons (when indicated). All patients of BCS received a tumor bed boost. Statistical analysis to compare the 2 groups for survival outcomes, was done in September 15. The primary endpoint was to compare the differences in loco regional recurrences (LRR) between the 2 groups. Results: Of the 463 patients, 209 received CFRT and 254 received HFRT. Median age was 48 yrs (IQR: 40-56), premenopausal (CFRT: 23%vs HFRT 39%, p = 0.005), and LABC presentation (CFRT36% vs HFRT 52%, p = 0.01) was seen in higher proportion of patients receiving HFRT. The commonest pathology was IDC (81%) with grade III tumors (45%), ER (+) was seen in 44%, TNBC in 34% and Her2Neu (3+) were seen in 27%. 254 patients (54.5%) had undergone BCS and 209 patients (45%) MRM 54% had left sided cancer and neoadjuvant chemotherapy (NACT) was given in 38%. The grade, HR status, laterality, NACT administration, BCS/MRM were similar in the 2 arms. For MRM patients, enface electrons were used in 88% patients treated with CFRT and 76% patients with HFRT. LN RT was delivered in 76% vs 64% in patients receiving CFRT vs HFRT respectively (p = 0.005). With a median follow-up of 40mo in CFRT (IQR: 14-55) and 29 mo in HFRT (IQR 17-38), 9/209 (4.3%) patients in CFRT and 7/254 (2.7%) in HFRT had LR. On univariate analyses, the 2yr actuarial LRFS in CFRT vs HFRT was 95% vs 97% (p = 0.37). The 2yr OS in CFRT vs HFRT was 81% vs 85% (p = 0.035) and 2year DDFS was 80% vs 83% (p = 0.15) respectively. Conclusion: The risk of local recurrence among patients of breast cancer treated with HFRT after BCS or MRM was not worse when compared to conventional radiation therapy despite a younger population with locally advanced clinical presentation in HFRT.
Phyllodes tumour of the breast: A retrospective analysis of 10 years data from a tertiary care centre
thS. S. Varghese
Christian Medical College, Vellore, Tamil Nadu, India, E-mail: [email protected]
Background: Phyllodes tumour of the breast is a relatively rare (<1%) of all breast neoplasms with diverse range of pathology and biological behavior. Aim: To describe the clinical course of Phyllodes tumour and to define the factors responsible for local recurrence. Materials and Methods: Retrospective analysis of hospital data of patients with Phyllodes tumour presented from 2005 to 2014 was done. Descriptive statistics was used to analyze the results. Results: Out of the 103 patients listed, 91 were eligible for analysis. The median age of presentation was 43 years and 2/3 was premenopausal. There was no side predilection, but 57/91 patients presented as an upper outer quadrant lump. 20% patients presented as recurrent tumour. 50% of patients presented as giant (>10 cm) phyllodes tumour. The median duration of symptoms was 12 months (Range: 1 - 168 months). 60% of patients had benign (B), 23% had borderline (BL) and 17% had malignant (M) tumours. The surgical treatment for benign histology included lumpectomy (L) (15%), wide local excision (WLE) (48%), and simple mastectomy (SM) (37%). All BL and M underwent WLE or SM. There was no recurrence in B and BL group when the margin was > or = 1 cm. All non metastatic M tumours received adjuvant RT, 46 - 50 Gy in conventional fractionation to the chest wall with tangents, irrespective of their margin status. 1/15 patients with M developed local recurrence. 4/15 M patients had distant metastases (Lung or bone). Our median duration of follow up was 12 months (Range: 1 - 120 months). Conclusion: Phyllodes tumour of the breast usually presents in middle aged women. It usually has a prolonged clinical course. Surgical resection with adequate margin gives excellent local control in B and BL types. Malignant phyllodes tumour will benefit from adjuvant radiotherapy.
A dosimetric comparision of cardiac dose in the left breast tangent field irradiation with or without deep inspiratory breath hold technique
thK. Sanketh , K. Beena, K. Sneha, M. Dinesh
Amrita Institute of Medical Sciences, Kochi, Kerala, India, E-mail: [email protected]
Introduction: Cardiac and pulmonary toxicities are a major concern for breast tangential field irradiation particularly in Left sided breast cancer patients who have a higher risk of having cardiac morbidities and mortality. The dose to the LAD which is suggested to be radiosensitive may play a role in lethal cardio toxicity. Respiratory gating radiotherapy substantially decreases cardiac doses. This study compares cardiac and lung doses using Deep Inspiratory Breath Hold (DIBH) Technique using Active Breath Control (ABC) Aim: To compare the cardiac, LAD, left lung doses and target coverage with and without DIBH. Materials and Methods: Forty five patients with left sided breast cancer who underwent breast-conserving surgery and adjuvant radiotherapy between November 2013 and September 2015 were included in this study. The Elekta Active Breathing Coordinator (ABC) was used for respiratory control and all the patients could hold their breath for 20-30 seconds. With a prior training of breath holding, simulation scans of both Free Breathing (FB) and DIBH with ABC were done. Two separate treatment plans were generated for each patient with and without ABC. Treatment plans were optimized with respect to the target coverage, dose conformity, maximum dose, beam energy and geometry. A dosimetric comparison was made between the two techniques for the heart, left anterior descending coronary artery (LAD) and the left lung. Results: Dose Volume Histogram was used for comparing the plans for the FB and ABC. In comparison with FB, ABC technique resulted in a significant reduction of 35% in the mean heart dose (244.2 cGy vs 159.2 cGy, p < 0.001). Mean dose to the LAD was reduced by 42% (1115.2 cGy Vs 640.88 cGy, p < 0.001). No significant difference was noted for left lung V20, mean lung dose. The ABC plans demonstrated significantly larger total lung volumes. Conclusion: We report that use of DIBH with ABC technique resulted in a significant reduction in radiation dose to the heart and LAD compared with FB technique. It improves critical organ sparing with the dosimetrically confirmed potential to decrease treatment-related late morbidity and mortality. So, this respiratory management strategy is a promising tool that may be routinely used for the treatment of left sided whole breast radiotherapy.
Motion of cardiac substructures: Analysis from ECG gated radiotherapy planning scans
thS. S Bisht, T. Kataria, D. Gupta, A. Abhishek, S. Goyal, T. Basu,
Medanta Cancer Institute, Medanta - The Medicity, Gurgaon, Haryana, India, E-mail: [email protected]
Background: Thoracic radiotherapy (carcinoma left breast, lung carcinoma, carcinoma esophagus, internal mammary chain irradiation) includes part of the left ventricle (LV) and left anterior descending (LAD) artery, right side of heart, right coronary artery. Radiation induced heart disease involves microangiopathy of small vessels as well as macroangiopathy of coronary arteries resulting in fibrosis of myocardium and coronary artery stenosis (CAS). CAS in segments receiving high radiation doses has been documented. Thus coronary arteries (CAs) must be must be delineated and critically protected during RT planning. Cardiac and respiratory motion induces variation in the position of CAs and other cardiac structures. Range of this variation and thus appropriate compensatory margin to be taken around the structures is not known. The present study assess the impact of systole/diastole and inspiration/expiration on motion of CAs and LV. This could help in delineating the CA more appropriately and thus protecting them during RT. Materials and Methods: Fifteen case of left breast cancer were included. Contrast CT scans were taken at normal Inspiratory breath hold and normal end expiratory breath hold, on Seimens 256 slice CT scanner with immobilization devices as per radiotherapy protocol. Total contrast used for the study was 1.5 mg/kg body weight. Half of this contrast was used in inspiratory phase and half in expiratory phase. In Monitoring phase, trigger was kept at descending aorta and was set at 80 HU in Inspiratory phase and 100 HU in expiratory phase. ECG gating was used during the scans. The software segregate the inspiratory scans into best systole and best diastole image sets. Similarly end expiration images were also segregated into best systole and best diastole image sets. Images were reconstructed at 1 mm slice thickness. Thus four image sets per patient were imported in contouring work station (Focal Sim). Inspiratory systole CT was primary and other three were secondary. LAD, right coronary artery (RCA), Left circumflex artery (LCX) and LV were delineated in all CT sets after fusion with primary CT using Heart atlas by Feng M (IJROBP 2011). Final contours were verified by radiologist. Motion variation for each structure was assessed by calculating the difference in all three (X, Y, Z) co-ordinates as provided by Focal Sim software. Mean variations in CAs, LV position in systole versus diastole in inspiration and expiration were calculated. Similarly mean variations in CAs, LV position in systole during inspiration versus expiration, and in diastole during inspiration versus expiration were calculated. Results: Mean variation (cm) of motion between systole and diastole in X, Y, Z co-ordinates for different structures were as: LAD 0.34 (0.17), 0.27 (0.19, 0.34 (0.32); LV 0.27 (0.26), 0.15 (0.13), 0.47 (0.23); LCX 0.6 (0.15), 0.18 (0.09), 0.48 (0.33); RCA 0.66 (0.32), 0.34 (0.23), 0.61 (0.36). Mean variation between inspiration and6 expiration in X, Y, Z coordinates for different structures were as: LAD 0.31 (0.13), 0.83 (0.08), 0.37 (0.20); LV 0.28 (0.1), 1.01 (0.20), 0.48 (0.13); LCX 0.19 (0.04), 0.95 (0.19), 0.61 (0.21); RCA 0.24 (0.09), 0.75 ( 0.17), 0.38 (0.12). Conclusion: Cardiac activity causes minimum movement of cardiac structures in cranio-caudal (CC) direction and large movement in anterio-posterior (AP), left-right (LR) direction whereas respiratory movements cause maximum movement in CC direction and minimum in LR direction. For CAs, LV radial margin of 6mm and CC margin of 4mm in breath hold radiotherapy, and radial margin of 6 mm and CC margin of 1 cm in free breath radiotherapy will cover the range of movements induced by cardiac and respiratory activity and can be recommended as internal risk volume (IRV) for these structures.
Comparison of hypofractionated radiotherapy schedule with conventional radiotherapy schedule in chest wall irradiation in post mastectomy breast cancer patients: A Prospective randomized study an interim analysis
thD. Malik , M. Gupta, V. Vyas, C. Waghmare
Mahatma Gandhi Institute of Medical Sciences, Sevagram, Wardha, Maharashtra, India, E-mail: [email protected]
Introduction: Radiotherapy is the standard treatment after breast onservation surgery and post mastectomy where indicated for preventing local recurrence and overall survival in breast cancer patients. The most common fractionation schedule practiced worldwide and in India is 50 gray in 25 fractions over 5 weeks. In recent years studies have been taken up to compare this conventional schedule with hypofractionation interms of efficacy and toxicity profile. We are comparing the conventional schedule with 40 gray in 15 fractions over 3 weeks in line with START-B trail. Aim: Comparison of acute radiation pneumonitis and acute radiation dermatitis between hypofractionated and conventional chestwall radiotherapy after mastectomy in breast cancer patients. Materials and Methods: Non metastatic post mastectomy breast cancer patients were randomized into two arms. Arm A received 40 grays/15 fractions/3 weeks. Arm B received 50 grays/25 fractions/5 weeks. The planned median followup is 18 months. This is an interim analysis where results of skin and lung toxicity at the end of 1 month and 3 months for the two arms are described. Results: At the end of 1 month, In Arm A, 73% had grade 0, 4% had grade I skin reactions, none had Grade II or higher dermatitis In Arm B 40% had grade 0 skin reactions, 60% had GradeI, none had Grade II or higher dermatitis. 6% and 20% patients continued to have Grade I dermatitis in Arm A and Arm B respectively at the end of 3 months. None had grade II or higher dermatitis in both the arms. (Confidence interval - 95%) None of the patients had pneumonitis at end of 1 and 3 months in both arms. Conclusion: At end of 3 months, hypofractionation schedule of 40 gray/15 fractions is superior to 50 gray/25 fractions with respect Radiation dermatitis. Incidence of radiation pneumonitis was nil in this interim analysis for both the schedules.
Dosimetric comparison of radiation doses to the left anterior descending artery by conventional and hypofractionation schedules in patients treated by 3DCRT for carcinoma breast
thS. S. George , P. A. Kingsley, R. Chandran, J. Sachdeva, S. Rathore, P. Negi
Christian Medical College, Ludhiana, Punjab, India, E-mail: [email protected]
Introduction: Radiation therapy in carcinoma breast patients play an integral part in the management. How-ever there is an increased risk of cardiac toxicity and non breast cancer related deaths. Damage to the key substructures of the heart especially the left anterior descending artery (LAD) is closely associated with the cardiac morbidity caused due to irradiation. Recent advances in treatment planning allows visualization of the cardiac substructures which guide us in tailoring the doses received by these structures and thus help in decreasing the potential toxicity caused by cardiac irradiation. Aim: To do dosimetric comparison of the radiation doses to the left anterior descending artery deliv-ered by conventional and hypofractionation schedules. Materials and Methods: 29 patients who received adjuvant radiotherapy for breast cancer in the Department of Radio-therapy in Christian Medical College and Hospital, Ludhiana between 01.09.2014 and 31.08.2015 were included. Patients were assigned to receive adjuvant external beam radiation dose of 50 Gy in 25 fractions over 35 days (Group 1 - conventional fractionation) and 42.5 Gy in 16 fractions over 22 days for intact breast irradiation (Group 2 - hypofractionation). All the pa-tients had been simulated with non contrast spiral computed tomography with 3 mm slice thickness. Delineation of the LAD was done in the treatment planning CT image sequences. Dosimet-ric data pertaining to the radiation dose received by the LAD was analyzed from the dose volume histograms and compared for patients in both the groups. Results: The mean and maximum dose to the LAD were observed to be more in patients with left sided breast carcinoma as compared to right sided tumours. The maximum LAD doses were seen to be higher in patients who received adjuvant radiation therapy by standard fractionation (Group 1) compared to hypofractionation (Group 2). The dosimetric parameters of V5, V10, V20 and V30 of LAD were observed to be higher in the hypo fractionation arm. Statistical analysis shall be performed and the observations shall be presented with significance values. Conclusion: In our study we observed that the maximum dose to LAD is more in the conventional fractionation arm and the DVH parameters were found to be more in the hypo fractionation arm. A prospective randomized study is needed to arrive at any conclusion regarding the dosimetric distribution. To comment on the benefit of fractionation on the cardiac effect, a longer follow up with cardiac investigations is needed.
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